Hair Transplant Q&A
If you have a question that you would like to have answered on our Hair Transplant Q&A, please Ask the Doctor.
Q: I’m currently 24 years old. Ever since turning 20, my hair on top began to thin little by little. I have noticeable thinning on the top part of my scalp and on my crown, but have no recession at the temples. My hairline looks amazingly young and hair on the donor areas seems quite thick. Am I in the early stages of male patterned baldness? I cannot place myself in the Norwood scale since my thinning doesn’t seem to follow the classic pattern. I just started on Propecia. Should I be considering a hair transplant? E.G., Union City, New Jersey
A: From the description, iIt sounds like you have typical Diffuse Patterned Hair Loss (DPA). Please see: The Classification of Hair Loss in Men for more information. In this condition, the top of the scalp thins evenly, the donor area remains stable and the hairline is preserved for a considerable period of time. Propecia would be the best treatment to start with. When the hair loss becomes more significant, patients with DPA are generally good candidates for surgical hair restoration. It is important, however, that before hair transplantation is considered, your donor area is checked for miniaturization to be sure that it is stable.
Q: I have early frontal thinning and was told that I am a Norwood Class 4A. I have been taking Propecia for several years. I recently went to see a doctor who told me go off Propecia and consider a hair transplant, since there is “no scientific evidence that Propecia works in the front of the scalp.” What should I do? CG, New York, NY
A: We have seen many patients who have had early thinning in the frontal scalp and who have re-grown hair (as evidenced by visual thickening) using Propecia. Although there have not been any scientific studies proving that finasteride works in the front, we routinely observe this in clinical practice. The fact that DHT causes frontal hair loss and that Propecia blocks DHT gives a logical explanation for these effects. The results are neither universal nor dramatic, but are real none-the-less.
We also often note acceleration of hair loss that begins a few months after stopping Propecia. Although one could argue that this may represent a natural progression of the hair loss, the timing usually speaks for a casual relationship with the medication. Although Merck did the studies in areas of the scalp where the effects would be most dramatic, there is no logical reason for Propecia not to work on miniaturized hair where ever these hairs may be – and to at least slow down hair loss in cases where it is not effective enough to cause frank regrowth.
As physicians, we are constantly using our clinical judgment in applying the results of a specific study to other situations. Why “stick to the book” on Propecia when the medication is so benign and the surgical hair restoration has such long-term implications for a patient? In our practice, we use Propecia as much as possible to decrease the number or extent of the hair transplant procedures. It is too bad that additional studies aren’t being performed to convert the skeptics.
Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? G.H., New York, NY
A: How much hair can be harvested in total depends upon a number of factors besides donor density, these include scalp laxity, hair characteristics (such as hair shaft diameter, color and wave) and actual dimensions of the permanent zone. Every person is different so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.
Q: I am 19 years old and seem to be thinning all over, including the sides. My father has all of his hair but my grandfather is totally bald. Should I have a hair transplant now or wait until I am older? K.C., Toms River, New Jersey
A: Most likely you have a type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA). In this hereditary condition, hair thins all over rather than just on the front, top and back as in the more common male pattern baldness. The fact that the back and sides of your scalp are thinning (the donor area) precludes you from being a candidate for surgery. The diagnosis can be made by observing a high degree of miniaturization (fine hair) in the donor area under a magnifier. This instrument is called a densitometer. For further information, please read the article Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning that was published in Dermatologic Surgery in 1997. Specifically look at the last part of the article.
Q: I have a scar on the top of my head the size of a quarter from an old injury. I would like hair to grow back on the bald spot. Can a hair transplant re-grow hair on the spot and not have any scar on my head at all? J.Y. – Trenton, N.J.
A: Traumatic scars are readily treated with follicular unit hair transplantation. The hair generally grows quite well in scar tissue as long as the scar is not thickened (hypertrophic). Several sessions are usually required. Although the hair restoration can make the bald area undetectable, the underlying scar tissue will still be there.
Q: I am 27 and have a Class 3 degree of hair loss. Should I should do a hair transplant or consider non-surgical methods of hair restoration? Y.G. Brooklyn, New York
A: At age 27, with early hair loss, you should consider the non-surgical options first. Propecia is the most important medication, but you need to be on it for a year at the full dose of 1mg a day to assess its benefits. If you have done this, and other parameters are OK for a hair transplant, such as adequate donor hair density & scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness) then hair transplantation can be considered.
Q: I am taking a baby aspirin to prevent heart disease and I heard that I should stop this medication before my hair transplant. How long should I stop for? J.D., Liberty, New York
A: You should discontinue the Aspirin 10 days prior to your hair restoration procedure. Other NSAIDs (non-steroidal anti-inflammatory drugs) need only be stopped 3 days before the hair transplant. Both Aspirin and other NSAIDs can be resumed three days after surgery. (Reference: Otley CC: Preoperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54:119-27.)
Q: I am 28 years old and was told that I have early Norwood Class 3 hair loss. I want to have a hair transplant but my doctor told me to use Propecia for 6 months and then come back to discuss surgery. I don’t want to wait that long, what should I do? K.J., New York, NY
A: Actually, you should wait a full year. If you are an Early Norwood Class 3, the Propecia can work so well (in actually growing hair back) that you may not even need a hair transplant. The important point is that Propecia only starts working at 3-6 months and during this time there may actually be some shedding as the new growing hair literally pushes out the old. A hair transplant performed at 6 months may not only be unnecessary, but growth from the medication may be attributed to the hair restoration surgery. I suggest to wait and see what the medication can do before going hair restoration surgery.
Q: I had some side effects from Propecia after being on the medication for about 10 days that included decreased sex drive and difficulty in holding an erection. I would like to try to continue taking the medication. What should I do? R.R., Tenafly, NJ
A: First, you should discuss this with your prescribing physician. In my practice, I generally advise patients to: Discontinue the Propecia until the side effects have gone then for 2-4 weeks, take 1/2 pill every other day (1 pill in 4 days). For the next 2-4 weeks take 1/2 pill every day (2 pills in 4 days). For the following 2 weeks, take 1/2 pill every other day, alternating with 1 pill every other day (three pills in 4 days). If you still do not have side effects, return to full dose of 1 pill every day. If you experience side effects during any 2-4 week interval, go back to the level that you had no problem and stay at that level for at least 1-2 months before trying to increase the dose again.
Q: I have had 4 hair transplants with strips taken out for a total of 2600 grafts over 15 years. The last one was 1,650 grafts. My doc says my donor site is good for a few more but I think it has been probably stretched to its max. Is it believable that the skin can be stretched to such extremes safely? H.K., Englewood, NJ
A: The scalp is very resilient to stretching, particularly in those with a loose scalp to begin with. After removing a strip, the laxity often returns to normal or very close to it within 6 months to a year. The problem with multiple hair transplant procedures is not only that scalp laxity may decrease, but that the donor density decreases as well. If too much hair is harvested, the donor area may eventually appear too thin. This may happen with either FUT or FUE. Therefore, it is important the doctor not only assess the scalp laxity, but the residual donor density.
Q: I’ll be traveling from New York to Cincinnati the week after my hair transplant. Will I be able to get through airport security if I have staples? O.L., Manhattan, NY
A: Yes, the staples that we use to close the donor area after the hair restoration, although made of stainless steel, are too small to be picked up by the metal detectors. I generally prefer staples as this method is superior to sutures in preserving donor hair.
Q: I have heard that you should take Propecia for 6 to12 months following a hair transplant. Is this correct? K.L., Forest Hills, New York
A: I would only use Propecia if you plan to continue the medication long-term. That said, Propecia is very helpful in preventing further hair loss and I do recommend that patients who have hair loss stay on the medicine for an extended period, regardless of whether or not they decide to have a hair transplant.
Q: If I had a hair transplant using FUT, how many grafts would be in a 15cm by 1cm donor strip on average. J.B, Brooklyn, New York
A: In a person with average donor density there are approximately 100 follicular units per square centimeter. A 15 cm long strip would have slightly less than 1500 grafts due to the tapering of the strip ends. Therefore, in a hair transplant of 1500 follicular unit grafts, one should take out a 17 cm x 1cm strip (that includes the tapered ends). This is 15cm2.
Q: I have developed a rather large, hard lump beneath the skin at the base of my scalp in the donor area that I first noticed this about two or three weeks after my hair transplant. What is this? K.W. – Tenafly, New Jersey
A: You are describing an enlarged lymph node. This is a normal part of healing in response to the surgery. It will resolve on its own in about 3-6 months. It doesn’t require any treatment and it should not be a cause for concern.
Q: Is it possible to use the strip technique with the extraction technique together? If so, would that hide the scar enough for me to wear my hair really short? G.J. – Brooklyn, NY
A: The combination of Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) used the way you are suggesting does make sense and is actually how I originally envisioned the two procedures to work together. The camouflage of the donor scar will probably never be necessary, but if it is desired, it should be postponed until after the last FUT procedure. FUE will make it possible for most people to wear their hair very short.
Q: I have had some surgical procedures on my head that left a fair amount of scar tissue. Can hair grow there? Is it a more difficult procedure? Are there any complications? L.E. New York, NY
A: Transplanted hair will grow in scar tissue as long as the tissue is not thickened. Thickened scar tissue can be flattened with local injections of cortisone. Once the scar is smooth, the hair transplant procedure is relatively straightforward; however a few things must still be kept in mind. Since the blood supply of the scar tissue is less than in normal tissue, the grafts should not be placed as close. As the grafts from the hair transplant grow, new blood vessels are formed in the area.
Additional density can then be achieved in a subsequent session by adding more grafts. After the hair restoration procedure, care must be taken with grafts transplanted into scar tissue, as the scarred scalp doesn’t hold onto grafts as well as normal tissue and they are more easily dislodged. If grafts are packed too closely into scar tissue, poor growth can result. If sites are placed properly and the post-op care is diligent, good growth should be expected.
Q: There is such a big deal made on the chats about people getting Megasessions of over 4000 graft per session. When I look at the pictures on your website, the results look great, but I am surprised that not many grafts were used compared to what is being talked about. K.R. – Jersey City, N.J.
A: My goal is not to transplant as many grafts as possible, but to get the best results possible without exhausting a person’s donor supply. It is important to keep reserves for future hair loss. Unnecessarily large sessions also risk poor growth and have a greater incidence of donor scarring.
Q: I am considering taking Propecia, but it I went to my local pharmacy in New York City and it is so expensive. Is there a way I can get it cheaper? J.M. – Brooklyn, NY
A: The website www.drugstore.com sells Propecia online at a reasonable price. A doctor’s prescription is required. Please note that Propecia is not yet available in generic form.
Q: I have been taking Propecia for three months. Would it help to up my dose? B.T – Scarsdale, New York
A: It seems that for most people (of average body weight of approx. 150 pounds) 1mg is the ideal dose. This is a statistical statement, however. There are occasional people who fall outside the bell curve. As we don’t know who these people will be, we generally increase the dose only on non-responders. It can take up to two years to see the full effects of the medication. Remember, an increased dose also increases the risk of side effects and for most people the greater dose offers no additional benefit.
Q: Do you ever see poor growth from a hair transplant? Q.H. – New York, NY
A: The situations where I have encountered poor growth are: 1) when hair is transplanted to areas of skin that has been thickened due to the prior placement of larger grafts or plugs” (this is called “hyperfibrotic thickening”), removal of the larger grafts can somewhat ameliorate this problem. 2) when hair is transplanted into a thickened scar, and 3) when a hair transplant is performed into and area of severe chronic sun damage. In this case, a very modest number of grafts should be used in the first session and if these grow well, additional grafts can be added in a subsequent session.
Q: I was wondering why you chose two years as the amount of time one should wait to judge the effectiveness of Propecia. Have you had patients who only saw results after that long? Why does Merck say 3-6 months and Dr. Rassman at New Hair say 6-8 months. I know these numbers aren’t arbitrary, but I’m just wondering what the logic is behind this and how does this relate to planning a hair transplant? KL, Fort Lee, NJ
A: The Merck data showed that over 90% of patients had peak response at 1 year and this has been my experience as well. Most patients show the most dramatic response between 6 to 12 months with some getting additional benefit up to two years. Prior to 6 months, the results are quite variable and there may even be a net loss due to shedding during this period, as the Propecia stimulates a new anagen cycle.
If one is planning to go on Propecia before a hair transplant to minimize any shedding from the surgery and to prevent future hair loss, one should start the medication at least one month prior to the procedure. If one want to use Propecia for the purpose of possibly avoiding hair restoration surgery, then one needs to wait at least a year to see if there will be enough regrowth. Finally, if one is younger, i.e. in the 23-25 age range, one should be on Propecia for at least two years to give it every possible chance of working and seeing its maximum benefit before considering a hair transplant.
Q: I am not yet ready for a hair transplant but am considering Propecia. What is your opinion on the “optimal dose”? I know Merck recommends 1 mg, but could I get away with taking less? Or would I get a better result by taking more (2-3 mgs)? G. H. New York, NY
A: You can probably get away with 0.5 mg a day, but there is a slightly greater incidence of non-responders at this dose than at 1mg. There is little evidence that a higher dose helps, but I often double the dose if a patient has been on 1mg a day for 3-5 years and then stops responding. This often can postpone the need for surgical hair restoration.
To read more Q & A’s with Dr. Bernstein or to view questions by category, visit our Hair Transplant Blog